Tuesday, July 27, 2010

"Okay, was this guy altered before?" asks the attending. "You want to call neuro and get a consult and see what's going on?"

"Wait," I pipe in. "Qué año es?"

"Dos mil diez."

"Gracias."

"He's not demented, he just doesn't speak English."

"Well why didn't he say so?" says the attending.

"Maybe he doesn't know how."

"Ugh."

And we leave. Scary enough, this is the highlight of my day. This is the moment of my day when it really crystallized for me-- I am a resident. I can do things. As an intern, it would have been hard to build up the courage to question the attending, hard to even suggest that this stupid little thing-- his assumption that the guy must be altered, which wasn't some big opinion the attending had formed, wasn't some big deal thing I'd be questioning, wasn't anything at all to the attending-- might be wrong. I would have waited until the end of rounds, then mentioned it to the resident, and hoped maybe she would say something to the attending, but then I'd have to follow up, I wouldn't want to make waves, it would turn into a whole big deal when it totally isn't.

But as a resident, hey, I know at least a little bit! I can make guesses. I can have opinions. And even though the attending is still technically my boss, I'm not scared of the attendings anymore. We're actually on the same team. We're colleagues. I'm just trying to help. I'm not afraid to be wrong-- if the guy had answered some crazy year in Spanish, I can just shrug it off and say, hey, thought maybe it was just a language thing, and we'd move on.

The interns, meanwhile, are looking at me like what I just did was crazy. Showed up the attending? That's crazy, weren't you worried, how did you know he didn't speak English, do you really speak Spanish, wow, that's amazing--

I don't speak Spanish. I speak fifty words of Spanish. How can you not speak fifty words of Spanish after a year in this job? I speak ten words of Chinese too. And three words of Tamil, I think.

Guaranteed I will have to convince at least five more people this guy isn't demented before he leaves the hospital... I should just hang a sign over his bed-- "Mental status: thumbs up. English: thumbs down." You know, I really should, it would help.

Wednesday, July 21, 2010

How can anyone not want to have kids?

I ask this, seriously, because there's pretty much nothing sadder than when a patient dies and there's no one to call. No family. No one. No one to bury them, no one to give their personal belongings to, no one to contact. It's like they never existed. They come in, they die, they're gone, and the entire world moves on like nothing happened.

And, yeah, having someone to grieve for you is a terrible reason to have kids, sure. If I think about it, it's a terrible reason, absolutely. Except the alternative seems so damn lonely. Friends go away when you get sick. Parents die. One spouse is (usually) going to die first. Nieces and nephews don't always care about you. Kids may not care either, but they show up. They hold your hand. They ask questions. They act like you matter.

Of course every patient matters, and no one's intentionally treating the ones who are alone in their rooms any differently from the ones with a constant stream of visitors, or a family holding vigil-- but it's absolutely the case that having someone in the hospital with you is a tremendous benefit. People make mistakes, and attentive family members sometimes catch them. Nurses and doctors don't always know the patient well enough to be able to tell when something's changing, when something's starting to go wrong. And having someone there means there's someone who can follow up if something seems like it's been forgotten, or to get the doctor when something's wrong. We're naturally going to spend more time in someone's room when there's someone to talk to, as opposed to when it's just the patient, alone, and hardly alert.

And when things are reaching the end? It's not a conscious decision, but how much motivation is there to fight for someone to last two more days when he has no one, he's suffering, there's no reason for someone in that position to still be alive. And maybe that's a good thing. Maybe families often fight too long, keep people alive for no reason, prolong the pain and suffering.

But I just can't imagine wanting to die alone. I can't imagine actively choosing a life where you've set yourself up for dying alone to be the most likely outcome. Obviously terrible things happen-- children predecease their parents, people become estranged, accidents happen without warning. But to intentionally set yourself up to be lonely in old age, to have no one-- it seems like such a tragedy.

It would be a shockingly unromantic Match.com profile. "Looking for someone to grieve when I die." But "looking for someone to grow old with" isn't so far off the point, and that's totally reasonable, right?

And yet this whole place-- this whole profession-- is so unfriendly to doctors with families. Residents can't take maternity leave-- they can take their four weeks of vacation in one chunk and then not get another break for a year. They can take (unpaid) time off but then they're off schedule for a fellowship and slow down their whole career. Everyone ends up working nights at some point, or at least being on call. You're on call every x nights, every x weekends, even in private practice. The job is priority 1. And 2. And 3. And maybe kids and a family can have some time after that. I know it's not unique to medicine, but you'd think medicine would understand. Medicine would know better. It doesn't. It's terrible. Pregnant residents are the subject of so much negative gossip-- "I can't believe she's having a baby" / "I can't believe she's taking 3 weeks off!" And residents with kids get no sympathy. "Why does he always want to leave so early?" Because he has a life and doesn't want to miss it. It can't be done in residency, it can't be done in med school, a woman who wants kids has to wait until she's in her thirties if she wants any semblance of a home life.

But why am I talking about this, I haven't been on a date in months. Ha.

Tuesday, July 20, 2010

Maybe working in the hospital is teaching me the wrong lessons. Maybe it should be teaching me to be more compassionate and more understanding and more willing to give you change from my pocket.

I used to sometimes give homeless people change. Or at least when I didn't, I felt bad about it, like I should. Like I don't know your story and maybe you really will use it for food, or something worthwhile.

But I don't believe that anymore, and it saddens me. Because all I can think about are the homeless people I see every day in the hospital, who are all in and out with alcohol withdrawal, drug withdrawal-- day after day, week after week, often the same people, days later, weeks later, months later. I know what they're spending their money on. I know where they're ending up time after time.

And maybe they're ruining it for the rest of you. Maybe it's just a few homeless people giving the rest of you a bad name, and you really do want a salad, or a piece of chicken. Maybe I was just naive before, and thought that this is actually what someone could possibly be spending my change on. But I don't even ask myself the question anymore, there's just no way I am reaching into my pocket and giving you any of my change, because it just means I'm going to see you that much quicker in the ICU.

Look, clearly doctors should not be solving the policy problems that lead to homelessness. Clearly, the issue is greater than what someone is doing with my change. By the time someone gets to a point where they're homeless and panhandling, we're probably far too late. And my instincts were probably wrong in the first place-- give money to organizations helping people in legitimate ways instead of to homeless people on the street. But just at a purely gut level, being exposed to the patients I see is absolutely making me a less sympathetic person in these cases. And that's sad, and also sort of unexpected. Shouldn't I see that these are medical problems, beyond someone's control? Shouldn't I be more able-- not less able-- to separate the illness from the individual?

But here's the thing-- I feel like I used to think that would absolutely be the case once I became a doctor-- wouldn't it totally bum me out to realize that we're all stricken by these terrible illnesses without deserving it, without doing anything to cause it, and it's a random crapshoot that anyone makes it through life unscathed. And, yeah, I absolutely see terrible things happen to people who didn't do anything to cause it. Cancers and worse.

But I also see a whole lot of things that people helped bring upon themselves, due to smoking, obesity, etc. I don't think I've seen anyone in three weeks without COPD, brought on by smoking. People complaining about their heart conditions and telling me they've been using cocaine off and on for 25 years. People who get injured riding motorcycles without helmets. Come on. If I've learned one lesson from this job-- don't ever, ever, ever, ever, ever get on a motorcycle. Ever. Ever. Never. I can't have that much sympathy for those patients. I have to save it. I have to save it for the ones who *really* didn't do anything to deserve what they have. I have to save it for the ones who I have no idea what they possibly could have done to prevent whatever they have.

And then I sometimes see these bitter attendings, who have no sympathy left for anyone, and it doesn't take a lot to figure out how they got that way. Which sucks and I don't want to be that way and, ugh, I don't know what the point of this post is. But, argh, I'm tired of sick people.

Thursday, July 15, 2010

Okay, I really can't do these overnights anymore. I just woke up. Got eight and a half hours of sleep, and now I have to somehow fit an entire day, breakfast/dinner/whatever, and some more sleep, into the next ten and a half hours before I have to go to work again.

I got zero minutes of sleep overnight. There were more transfers to the ICU in one night than in the previous four. We got slammed, and there was nothing I could do about it. I'm in with one patient, whose blood pressure is 70/30, and then the nurse calls me into the room next door, 60/40, and then my intern calls a code on a guy across the hall who's in v-tach (ventricular tachycardia) and of course I'm the code leader, and of course I get to do my first ever defibrillating. Obviously I'd practiced shocking robots and fake patients, and I guess I'd seen it done a couple of times, but I'd never been the one doing it.

And this guy was some sort of mutant life form who didn't seem to need a properly beating heart in order to function. The way you see it on TV-- and, hey, the way I'd seen it before in real life-- is that someone needs to be shocked, they're not in good shape. They're lying there, out of it, not acting like a normal, live, person. Not this guy. He was talking, joking, asking questions. We're giving him electrical shocks, and he's barely noticing.

"No one gave me any f--ing food--"

"Clear!" [I shock him]

"Ow, that hurt. What the f-- is everyone staring at me for? I just want to watch the damn TV."

"Clear!" [I shock him]

"Ow! Where are my friends? My friends said they were going to visit--"

"Clear!" [I shock him]

etc.

We got him back to a stable rhythm, but the whole night was one crashing patient after another after another. I didn't go to the bathroom for ten hours. At 4AM, the floor resident calls me and says she's sending over two new patients. At 4AM.

In the morning, the attending asks me how the night was-- I can barely even stand at this point, every bed is full, how does he think the night was? And he expects me to be able to present a case to him? I can't even keep my eyes open.

And now I just want to go back to sleep again. Which I might very well do.

Wednesday, July 14, 2010

I dream about my patients.

I dream that they're dying and I cannot save them. I dream that they're screaming at me and I cannot calm them. I dream that they're stabbing me with syringes before I can stab them. I dream that they're turning me into the hospital's Board of Directors, an institution I have never encountered in person but seems to appear in a third of my dreams, as vivid as anything.

One of my interns has a wife who brings him dinner when he's working overnight. I bring my own dinner. And it's microwavable. And I eat it, in the call room, alone, while I wait for a nurse to page me that someone needs help. Apparently the other residents don't let the interns have a 15-minute break for dinner. Apparently I'm a pushover. Because I help and don't yell. It's weird-- there are 3 residents, we take turns being on overnight, and on the days we're not on call, we only see each other for a few hours in the morning-- if you were on call the night before, you leave by noon; if you're on call the following night, you leave by two. So it's like we're living parallel lives. We have the same patients, we transfer information in the morning, but we're really not working together. The interns, on a different rotating schedule, get to see all of us, and they become the conduits of information. They tell me about what my co-residents have been doing, they tell me what things were like while I was sleeping. So it's not like I can directly compare my behavior to my co-residents and see on my own whether I'm the good cop or the bad cop. I find out from the interns. And they tell me I'm good cop. But I don't feel like good cop. I make them do what I think they need to do, and try not to unnecessarily torture them or keep them from any sleep that they're able to get overnight. I mean, two weeks removed from being in their shoes, it's not like I don't know the difference between being a fair resident and being a jerk. So I try not to be a jerk. And apparently that makes me exceptional. At least in their eyes, two weeks in. Do I want to be the nice guy? Do I want to be the pushover? Not really. But I guess it's better than the opposite.

Monday, July 12, 2010

I think we're coming up on 29 hours in a row. This shift started out so easy. Weekends are slow. Very few people get admitted to the hospital on the weekend. At first I didn't understand-- certainly people are no less likely to have a heart attack, get sick, fall, etc on the weekends. And if anything, on the weekend people might have the flexibility to come to the hospital instead of having to deal with taking time off from work. But I think most of it is that a lot of people end up in the hospital because their doctor puts them there-- they have an outpatient appointment, and something's wrong, and they're sent to the hospital. Most outpatient facilities don't see patients on the weekend. Hence, they wait until Monday, and that's when they come in.

So, anyway, slow day, no admissions, thought it would be an easy night....

And then we get a 30-year-old woman, a walk-in off the street, complaining of chest pain... the ER resident moves her along to my team, nothing serious...

And then she dies.

I mean, I say that like it happened instantly. It didn't. I spent ten hours trying to keep this patient alive. We called three codes. We intubated her, we tried one medication, we tried another, we tried a cocktail of everything we have... and maybe that just made things worse, maybe it didn't make any difference at all, maybe maybe maybe maybe... but who knows. We called the attending-- two attendings ended up coming in, from home, on a Sunday evening. They couldn't do any better than the rest of us did. Whatever we did or didn't do, whatever was happening to this patient... she died. She walked in off the street, alert, talking, alive... and 10 hours later she was dead. And we still don't quite know why.

I feel like from an outsider's perspective, people expect that this is what happens all the time in the hospital-- people show up, sick, and they die. Doctors can't save everyone, people are going to die, it happens. And it does. But usually not this fast, and not with so little to explain it. We know when people are dying. We know when we can't fix things. Even if I don't know, personally, the attending knows, the fellow knows, someone knows. Yes, the progression of disease is different for everyone, and sometimes Plan A works, and sometimes Plan A doesn't work. But there's a plan. We can control the death to some degree-- or we can prepare for it-- or we can, I don't know, feel like we're one step ahead of what's happening, even if we can't change anything.

Except this time we weren't. We were nineteen steps behind. I told my intern at 9:30 last night, "I think we've finally got her stable, we'll figure out what's going on in the morning." And then by 11:00, I was calling the family to tell them things are not looking good, and they should prepare themselves for the worst-case scenario. And then at 2:00 I was telling them they should get here early in the morning to talk to the doctor. And then at 4:00 I was telling them she was dead.

I feel like all year, the mistakes I've seen have all been very tangible. The patient should have had test X, medication Y, treatment Z. Someone should have picked up on lab value Q earlier. Someone should have seen or done something, or messed up something. This case, who knows. On the one hand, I feel like of course there should have been *something* I could have done, something I missed, something that could have helped. On the other hand, we have no idea. The attending didn't know what to do differently. No one knew what to do differently. No one knew what to do at all. No one knows what we should have done.

The fact that we can see the future, in most cases-- we can predict, pretty reasonably, what's going to happen, even if we can't stop it-- is a powerful thing. I feel powerful, as a doctor, usually. I do. Even if I don't feel comfortable admitting it. It's power, to know if someone is going to live or die a day before it happens. It's sad and pointless and ridiculous power, but it's something to hang onto, something to use to say to yourself, hey, I'm a doctor, I know things, I'm actually qualified to do this job, at least a little bit.

But something like this happens and it's like, what's the use of us? We did nothing, we know nothing, we either killed someone or at least didn't prevent them from dying, we gave them zero extra minutes of life, we are... useless. Worse than that, because we hold ourselves out as being useful, good, smart.

Friday, July 9, 2010

Maybe I shouldn't be blogging when I've had 3 hours of sleep in the past 36 hours, coming off a 29-hour shift where we got a new patient at 2AM that kept me from getting any sleep overnight and then I could barely sleep during the day because my body is all messed about what time it is....

So while I couldn't sleep I watched this ridiculous medical show on TNT called Hawthorne that someone told me to record for some reason. Anyway, not to spoil anything, but do they even have a medical consultant on this show? Is someone even bothering to see if what's going on makes any sense?

People get run over by a car in front of the hospital, and the nurse manager yells at the people about to go help-- "no-- call 911!" What? So the ambulance can bring them 10 feet to the door? What is she talking about? What's the ambulance going to do? Go help the people! Although after watching the rest of it, they should have called 911, and they should have brought them to a different hospital, where things actually make sense.

One of the people hurt is a surgeon at the hospital. They diagnose him by looking at his arm, and decide he might have nerve damage because they can apparently perform medical tests with their mind. A few hours pass. "It's been a crazy day. Tell the night shift to come in early," the nurse manager tells someone-- as if that makes any sense, and as if there's some special way to get an entire hospital staff to magically show up to work when they're supposed to be off. That's a minor point, I know, but it bothered me, as someone who has worked nights, and would not appreciate someone calling me and telling to come in early because the day was busy. Ha.

So then the doctor with the magic injured arm is told he needs surgery, and they're going to do it as soon as possible. In the middle of the night. Yeah, because non-emergency arm surgery is done in the middle of the night, surgeons work 24 hours a day, the ER is always available, and why wait until normal working hours, right?

And then it gets insane. The head nurse, who seems to be in a relationship with the injured doctor, tells him that she lives right nearby, they should go to her place and then he can come back when they're ready for him in surgery.

Uh, WHAT? First of all, arm surgery isn't happening in the middle of the night. But even if it was-- patients can't just leave the hospital and come back for their surgery. They're not going to, I don't know, prep him for the procedure?

So they get to her house, and she's like, "can I get you something to eat or drink?"

Excuse me? Does she work in a hospital? Has she been around patients ABOUT TO HAVE SURGERY? Patients who are about to have surgery don't eat or drink. That's not, "oh, it's okay because he's a doctor." No, you're having surgery, you don't get food. Period. I actually stopped and re-watched this scene three times, because it was so absurdly ridiculous.

And then, having magically regained the use of his arm, he proceeds to have sex with the head nurse on her floor.

Tuesday, July 6, 2010

Okay, new theory. The road to becoming a doctor is like a crash course in corporate hierarchy. Usually you don't go from floor-sweeper to middle management in a year-- and with no time to adjust. And, who says the people who are good at doing stuff are necessarily going to be good people-managers. The reason a lot of my residents were hard to deal with is because being a resident is a silly job that doesn't have a lot to do with how good a doctor someone is, and how much medicine they know. Okay, it has something to do with it-- you're going to be a terrible resident if you don't know your medicine and you can't make the right calls about your patients and what needs to be done. I guess I'm just saying that the medicine, while necessary, is by no means sufficient. A week ago, I was spending my day taking orders and executing. Now I need to spend my day doing things like "keeping my interns motivated" and "being a good leader."

A week ago, I would complain the job was too much like being a secretary. Now, it's too much like being a summer camp counselor. I brought cupcakes for my interns! Cupcakes! I am a grown man, and I went to a store and bought cupcakes just so I can be the "favorite" resident and the interns will like me. You know why? Because I had to spend all day yesterday listening to the interns complain about how mean my co-resident is (it was her day off) and how they hate her. And I don't want them to spend my day off complaining to everyone about me. "She made us draw blood on our first day!" Yeah, drawing blood sucks, and the nurses should do it, but they don't. And not that I love my co-resident, but she's fine, and she doesn't deserve to be bashed all day. And, yeah, back oh so long ago when I was an intern, sure, I complained about the residents, but, ugh, I'm bribing them with cupcakes. Is this what doctors should be doing? Buying cupcakes?

I think maybe I'm more tolerant than my co-residents because it's not as if I came in as an intern with a ton of confidence about my clinical skills. I expect the interns are going to be slow and know nothing. I expect their instincts aren't going to be right yet. I'm much more competent than I was a year ago. I don't expect my interns to necessarily be better than I was, so I'm not surprised when they're not. I don't expect them to know things I didn't learn until 6 months in, so I don't care if they don't, and I'm happy to teach them. I think my co-residents expect fully-formed doctors on day one, and don't know how to babysit and train. And on the one hand, good for me that I can manage my expectations and do the job of a camp counselor. But on the other hand, it doesn't make my co-residents bad doctors because they don't know how to teach. No one taught us these skills, no one gives us a handbook, we're not evaluated for residency based on how well we're going to teach the people below us.

And that's maybe a problem with the system. In medical school, you're taught by teachers. At least nominally, the doctors teaching us are actually teachers. There has been some weeding out process, some self-selection about who goes to a teaching hospital and teaches med students, and some hiring and evaluation process. If you're not interested in teaching, you probably end up somewhere else. Good, fine, doesn't make you a bad doctor. But then in residency there's no less teaching going on-- it's just that your teachers have no experience, training, or, in many cases, desire to be teaching. EVERYONE has to have a residency to be a doctor. So EVERYONE ends up having to teach people below them, no matter what you want to end up doing, no matter whether you're a great doctor/mean person, or anywhere on the continuum. So the system is screwy. Intern year sucks because most of the people who are supposed to teach you aren't good teachers and don't want to teach. And then residency sucks for all of those bad teachers, because they're forced to spend most of their time teaching instead of doing.

I hate cupcakes. I really do. They're so sickeningly sweet, I don't know, it's not that I don't like dessert, but cupcakes are so one-dimensional. But people like them, right? It makes me the good cop if I bring them cupcakes while my co-residents yell about blood draws, right? And I get to feel nice and smug that I'm the good resident and my co-residents are the enemies. Should be a fun month!

Not to make this about me, but, come on, this guy has three women clamoring for his affection, and I can't even find one?

I'm kidding, sort of, but it's actually sort of amazing to see the variety of family structures and relationships that patients have. The dynamics in so many families seem so completely messed up, no doubt in part because of whatever medical issue is in play, but even besides that, I can't imagine some of these relationships are functional even outside the hospital context. People who cannot say two sentences to each other without screaming and fighting about it. People who don't even seem to like each other, yet who will show up day after day to visit. And people who've been together for years who won't visit at all.

On a practical level, what I've seen over this past year has made me realize how important it is for people to have the conversation with their families about what they want as far as treatment. It's not surprising that most people don't-- it's a terrible conversation to have-- but "he would never want to live this way" and "he would never want us to just let him die" as two sides of the DNR continuum-- it's helpful to know where someone falls, and more often than not, family members don't know, and can't simply divine the answer.

The running joke all day yesterday-- you have to have something to keep you going when you're working on a holiday-- was whether we'd get to see red, white, and blue. And of course we did. One patient bleeding out, one patient losing blood flow to one of his extremities, and one patient who couldn't breathe. Happy 4th of July.

Friday, July 2, 2010

Jumping right from intern to resident-- with barely a 12-hour break in between-- is a little strange. I feel like I'm training people to do my job, while I'm still doing it. Which I guess is exactly what it is, but still.

I'm noticing stupid things, like I'm not used to being able to go to the vending machine without clearing it with my resident first. It felt crazy to just decide, hey, I'm hungry, I want a bag of pretzels, and "sneak off" without making sure my resident was OK with the three minutes I'd be gone. Maybe that means my residents have mostly been insane, because I didn't really care if my interns went to the vending machine. Assuming they weren't doing it in the middle of a code, but, you know, generally, uh, who really cares.

One of the other residents came into the call room and started introducing himself to the interns, confident, a little intimidating, "Hi, I'm Jack, I'm one of the residents, but don't worry, I'm nice to interns." Come on, yesterday you WERE an intern. YESTERDAY. These people are you, one day later. Why are you trying to make yourself feel important?

It's strange to realize how much I've learned over the past year-- it's hard to notice when you're in it, day after day, but the interns were asking questions that absolutely seem silly now, but of course they weren't silly to me a year ago.

"How long should the notes be?"

"What do you say in the note if the lab hasn't come back yet?"

"Do we call the doctors by their first name or last name?"

One of the interns has off today, because she's overnight tomorrow, so if you're overnight on Saturday, Sunday is your post-call day (so it's not really a day off), so you get Friday off as your "weekend" day. I'm telling the intern I'll see her on Saturday, and she looks at me--

"Oh, no, I'll come in tomorrow--"

"No, you're off."

"It's silly for me to take off on my second day! I'll come in!"

"No, it's your day off, why would you want to come in?"

"I just started, I don't need a day off."

"You'll need it after your 27-hour shift. You're off. Don't come in."

"Not even for a little while?"

"No. Sleep. Read. Anything. You work 6 days a week. You need a day off. And someone else will be covering your patients anyway."

"Well, if you're sure."

"I'm absolutely sure. Do not come in on your day off. That's one of the only good things about being a resident. Your hours are your hours, when you're off, you're off, no one will tell you to come in."

"Okay. But I'm worried I'll miss something important."

"Nothing that won't happen twenty more times before the year is over, I'm sure."